Sepsis was formerly defined as documented or suspected infection plus two sirs criteria. In contrast, the 2012 guidelines define it as documented or suspected infection plus “some” of a long list of conditions:

Fever (greater than 38.3°C)

Hypothermia (core temperature less than 36°C)

Heart rate greater than 90/min–1 or more than two sd above the normal value for age

Norepinephrine as the first choice pressor (former guidelines did not specify norepi versus dopamine).

Note that norepinephrine is not always to be delayed until volume resuscitation is complete. From the guideline document:

Vasopressor therapy is required to sustain life and maintain perfusion in the face of life-threatening hypotension, even when hypovolemia has not yet been resolved. Below a threshold MAP, autoregulation in critical vascular beds can be lost, and perfusion can become linearly dependent on pressure. Thus, some patients may require vasopressor therapy to achieve a minimal perfusion pressure and maintain adequate flow (133, 134).

What if norepi isn't enough? The implication is that epinephrine is next followed by vasopressin, but the guidelines lack clarity as to which to use first and why. Again, quoting from the document:

We recommend norepinephrine as the first-choice vaso-pressor (grade 1B).

We suggest epinephrine (added to and potentially substituted for norepinephrine) when an additional agent is needed to maintain adequate blood pressure (grade 2B).

Vasopressin (up to 0.03 U/min) can be added to norepinephrine with the intent of raising MAP to target or decreasing norepinephrine dosage (UG).

Neuromuscular blockers for ARDS but only early, only if PO2/FiO2 below 150 and only for up to 48 hours. The 2008 guidelines suggested blanket avoidance of neuromuscular blockers.

Relaxed glycemic control targets (180 in the new guidelines as opposed to 150).